Supportive Care 2

8/8/2019 Supportive Care 2

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91W10

Advanced IndividualTraining Course

Clinical Handbook

Supportive Care 2

Department of the ArmyAcademy of Health Sciences

Fort Sam Houston, Texas 78234


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Academy of Health Sciences91W10

Field Training Workbook - Index

i

Manage a Seizing Casualty.....1-8 Determine type of seizure Assess the casualty and overview of differential diagnosis Provide emergency medical care Provide on-going management

Assist in Vaginal Delivery...9-20 Stages of Labor

Care for Normal Delivery Outside the Hospital Monitor for complications during labor Predelivery Emergencies Identify additional gynecological emergencies

Perform Medical Screening....21-28 Screen medical records for accuracy and completeness Screen immunization records for accuracy and completeness Screen for personnel / administrative matters Screen Dental Records Ask and record the following Medical History information on the prescribed form Perform a patient examination Disposition Plan

Immunization and Chemoprophylaxis....29-36 Personnel subject to immunizations and required shots Chemoprophylactic Requirements

Pre-administration Screening Vaccine Handling, Administrative, and Patient Care Procedures Reactions and possible side effects Documentation

Specimen Collection.......37-40 General principles for throat culture and sputum collection Stool specimens Urine specimens Blood specimens

Blood Draw.....41-45 General Considerations Steps and Procedures to Perform a Venipuncture

Appendix A Specimen Collection, Competency Skill Sheets

Appendix B Blood Culture, Competency Skill Sheets


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Manage a Seizing Casualty

1

TERMINAL LEARNING OBJECTIVE

Given a standard fully stocked M5 Bag or Combat Medic Vest System, given a casualtydisplaying seizure activity. No other injuries are identified. IAW Emergency Care in theStreets, Prehospital Emergency Care, Trauma AIMS

Types of seizureIdentify cause of seizure

(1) Failure to take prescribed anti seizure medication; most commoncause of seizures in adults(2) Trauma - may occur following head injury (Has the casualty fallen?

Has casualty been hit in the head?)(3) Congenital brain defect - most often seen in infants and children(4) Infection - causes swelling or inflammation of the brain (meningitis or

encephalitis)(5) Fever - seen in children 6 months to 3 years of age usually with

temperatures above 103 degrees; rarely in older children or adults(6) Metabolic disorders - irregularities in body chemistry

(diabetes/hypoglycemia)(7) Drug toxicity - drug/alcohol use or abuse or withdrawal(8) Brain tumor - may manifest as a seizure(9) Previous trauma - scars on the brain from previous injuries(10) Idiopathic - An idiopathic seizure is spontaneous. The cause of the

seizure is unknown. It often starts in childhood.(11) Hypoxia - lack of oxygen to the brain

(12) Hypertension - blood pressure is too high; seizures may beassociated with cardiovascular accident (CVA)

Signs and symptoms(1) Generalized seizures

(a) Tonic-clonic seizure (grand mal seizure)"Tonic" is muscle tension (stiffness or rigidity)."Clonic" is the alternating contraction and relaxation ofmuscles in rapid succession.

(i) May or may not be preceded by an aura(ii) Loss of consciousness occurs(iii) Characterized by tonic/clonic seizure activity

throughout the entire body(iv) Lasts several minutes (1 to 3)(v) Following by a postictal phase (the patient is

confused, drowsy, or unconscious)(vi) Type of seizure that most people associate with

epilepsy and other seizure disorders(b) Absence seizure (petit mal seizure)

(i) Demonstrates temporary loss of awareness toenvironment

(ii) May appear to be daydreaming or staring intospace

(iii) Eyelids may flutter rapidly


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(iv) The person may become unresponsive for a fewseconds, then, immediately resume the task hewas doing prior to the seizure. The Individual iscompletely unaware that anything unusual hashappened.

(v) No tonic or clonic activity

(2) Partial seizures

(a) Simple partial seizure (also called Jacksonian seizure)(i) Characterized by tonic and/or clonic movementsin only one part of the body

(ii) No loss of consciousness(iii) May progress to a generalized seizure

(b) Complex partial seizure (also called psychomotor ortemporal lobe seizure)(i) Usually preceded by an aura(ii) No loss of consciousness(iii) May be characterized by confusion, glassy

stare, aimless movement, fidgeting, lipsmacking, and chewing. The person mayappear drunk or on drugs.

(iv) May progress to a generalized seizure

(3) Status epilepticus(a) Two or more seizures without a period of consciousness

between each seizure or a seizure lasting longer than 30minutes(i) Permanent CNS injury is more likely to occur the

longer seizures are allowed to progress(ii) Initiate treatment if continuous seizure activity

lasting more than 10 minutes(iii) The longer the seizure is allowed to continue the

more difficult it will be to control(iv) Tonic/chonic activity present; may cause long

bone and spinal fractures(v) Convulsive activity may gradually lessen over

time giving impression that seizures havebeen controlled

(vi) Correct diagnosis requires a high index ofsuspicion, a perceptive physician andsometimes an EEG

(b) Patient does not have time to breathe well or time torecover between seizures (hypoxia)

(c) True medical emergency - receives highest priority fortriage and transport in mass casualty situations

Assess the casualty and overview of differential diagnosisReport a detailed history of the seizure activity

(1) Physical description(a) Gradual or abrupt onset


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(b) Progression of motor activity(c) Loss of bowel or bladder control(d) Activity local or generalized(e) Duration of the attack(f) Ask patient if they have any recollection of the attack

(2) Clinical context of the seizure activity(a) Patient known epileptic

(i) Missed doses of antiepileptic or recentalterations in medication(ii) Sleep deprivation(iii) Alcohol withdrawal(iv) Infection(v) Use of other drugs

(b) No previous history of seizures(i) Symptoms that might suggest previous

unwitnessed or unrecognized seizures* Blank or staring spells in school* Involuntary movements* Unexplained injures* Nocturnal tongue biting* Enuresis

(ii) History of recent or remote head injury(iii) Persistent, severe, or sudden headache(iv) Concurrent pregnancy or recent delivery

possible eclampsia(v) History of metabolic derangement or electrolyte

abnormalities, hypoxia, systemic illness(especially cancer), coagulopathy oranticoagulation, drug ingestion or withdrawaland alcohol use

General physical examinationIs directed toward discovering any injuries, especially to the head orspine, resulting from seizure.(1) Possible fractures, sprains and bruises(2) Tongue lacerations(3) Assess for precipitating factors. Search for any systemic illness

that may have caused the seizure.(4) Assess vital signs, note temperature(5) Assess blood glucose level, if equipment available(6) Assess for motor system coordination, strength and tone(7) Assess for slurred, very weak or hoarse speech(8) Assess for jerky, uncoordinated, slumped or slow movements in

posture and gait(9) Assess for incontinence of bladder and bowel

Differential DiagnosisMany episodic disturbances of neurologic function may be mistakenfor seizures.


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The following are several of the more important entities that shouldbe considered.Syncope

(a) Symptoms: may include some or all of the following:dizziness, diaphoresis, nausea, and "tunnel vision"

(b) Patient is usually aware they are going to faint(c) Can describe onset of attack

(d) Cardiac Syncope may occur suddenly without any warning(e) Injury or incontinence may occur

Pseudoseizures (extremely difficult to distinguish from trueseizures)

(a) Pseudoseizures are psychiatric rather than neurogenic(b) Associated with conversion disorder, panic disorder,

psychosis, and impulse control disorder(c) May occur in response to emotional upset(d) Attack will occur with witnesses present(e) Incontinence, injury, postictal confusion and lethargy are

uncommon

Hyperventilation syndrome(a) Gradual onset(b) Shortness of breath, anxiety, and perioral numbness(c) May progress to involuntary spasm or the extremities and

even loss of consciousness

Migraines(a) Similar to aura of partial seizures

Movement disorders(a) Dystonia, chorea, myoclonic jerks, tremors, or tics may

occur in a variety of neurologic conditions(b) Consciousness is always preserved during movements(d) Involuntary but can be suppressed by patient

Clinical features that help to distinguish seizures from other kinds ofmimicking attacks include:

(a) Abrupt onset and termination(b) Lack of recall(c) Movements of behavior during the attack generally are

purposeless or inappropriate(d) Attack is followed by a period of postictal confusion and

lethargy (except for petit mal or simple partial seizures)


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Provide emergency medical careTreatment

During a seizure(a) Position the patient on the floor or the ground. Move the

furniture with edges away from the patient (GOAL: preventself-injury)

(b) DO NOT RESTRAIN the patient during a seizure(c) DO NOT force anything into the patient's mouth

WARNING: Bite sticks have been bitten and swallowed resulting in anairway obstruction. Teeth and jaws have been broken due toforcing a tongue blade into the mouth. NEVER use fingers tokeep the patient's teeth apart.

(d) Observe and record time of onset, duration, characteristicsof the seizure, and if the patient was incontinent of stool orurine

CAUTION: If the casualty's teeth are clenched, do not attempt to forciblyopen the casualty's jaw. Do not restrain the casualty's limbsduring seizures.

After a seizure(a) Maintain an open airway

(i) Position casualty to maintain open airway

(ii) Clear airway(iii) Insert airway device to assist with maintaining

open airway, if needed(iv) Support and stabilize cervical spine, if suspected

injury(b) Turn patient on his side if no spinal trauma is suspected

and suction his mouth as needed(c) Administer high-flow oxygen. Use a non-rebreather mask

if the patient is breathing on his own. Use BVM withreservoir to ventilate if patient is NOT breathing on hisown.

(d) Monitor vital signs(e) Protect the patient from embarrassment. Cover the patient

if exposed or clothes are torn. Keep spectators away fromarea. If patient loses bladder/bowel control, clean and/orcover the patient as soon as possible.

(f) Establish and maintain intravenous access(g) Administer IV fluids cautiously

Administer pharmacological interventions(a) Valium

(i) Therapeutic effects* Suppress seizure activity in the motor

cortex of the brain


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* Generalized central nervous systemdepressant

* Muscle relaxant(ii) Indications

* To treat grand mal seizures/statusepilepticus/seizures lasting greaterthan 10 to 15 minutes

(iii) Contraindications

* Should not be given during pregnancy- exception may be seizuresassociated with eclampsia

* Should not be given to patients withhypotension/decreased systolic BPless than 90

* Should not be given to patients withrespiratory depression. Respirationless than 10 per minute

(iv) Side effect* Possible hypotension* Depression in the level of

consciousness(v) Administration and dosage

* For grand mal seizures/statusepilepticus give slow IV in titrateddoses. Can be given intramuscular,

rectally, or via endotracheal tube ifneeded. Start with 2.5 mg. Monitorvital signs. If vital signs are stable andpatient is still seizing, give another 2.5mg of Valium slow IV push. Continueuntil the seizures have stopped. Donot exceed total dosage of 10 mg.

(vi) Incompatibility* Should not be mixed with any other

drug(b) 50% Dextrose (D50)

(i) Therapeutic effects* Rapidly restores blood sugar level to

normal level(ii) Indications

* To treat suspected hypoglycemia* To treat status epilepticus

(iii) Contraindications* Intracranial hemorrhage* Known stroke

(iv) Side effects* Will cause tissue necrosis if it

infiltrates


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* May precipitate severe neurologicalsymptoms in alcoholics (Wernieke'sEncephalopathy)

(v) Administration and dosage* 50 ml of 50% solution (25 gm) slow

IV. Supplied in pre-filled syringescontaining 50 ml of 50% solution.

* Determine serum glucose if possible

prior to administering glucose(c) Ativan (Lorazepam)(i) Indications

* Anxiety disturbances or anxiety states:general anxiety disturbances panicdisturbances phobic anxietydisturbances

* Adjustment disturbances with anxietyor stress reaction

(ii) Contraindications* Assess patient periodically* Safety and efficacy in children under

the age of 12 has not beenestablished

(iii) Dosages* ADULT dose for anxiety is: 2mg - 3mg

daily in 3 - 4 divided doses

* RANGE: 1mg - 6mg daily in divideddoses

* ELDERLY/DEBILITATED PATIENTS:Initial dose of 1mg - 2mg/day individed doses. Adjust as needed andtolerated.

* In elderly and/or debilitated patientsand in those with serious respiratoryor cardiovascular disease, a reductionin dosage is recommended

* In the case of local anesthesia anddiagnostic procedures requiringpatient co-operation, concomitant useof an analgesic is recommended.

* Ativan sl: Dosage of ativan sublingualshould be individualized for maximumeffect.

CAUTION: The soldier medic must be proficient and competent in drugadministration. This includes knowledge of therapeutic effect,indications, contraindications, side effects, how supplied,administration, and dosage of the drugs.

(d) After the seizure activity is over, assess and treat anyinjuries suffered during the seizure


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(e) Expect lethargy, partial consciousness, and disorientation(f) If possible, try to determine how long the seizure lasted,

what the patient did after the seizure, and what the patientwas doing prior to the seizure

Transport considerationsRequirements

(a) Patient with a first time or new seizure

(b) Patient with a seizure that caused injury(c) Patient with respiratory difficulty(d) Status epilepticus patient - immediate transport

Maintain an open airwayPatient should be transported on his side while being givensupplemental oxygen en route to the medical facilitySuction mouth as neededMonitor vital signs while en route

Provide on-going managementMaintain the casualty on their side, if necessaryMonitor the casualty's airwayMonitor vital signs to include pulse oximetry, if availableMonitor neurological status(1) Pupil response(2) Glasgow coma scale

(a) Eye opening

(b) Verbal response(c) Motor response

Place the casualty in a quiet, reassuring environment, if possibleMonitor IV fluids.Reassess pharmacological interventions every 15-30 min.

CAUTION: Sudden, loud noises or bright light may cause another seizure

Document seizure activity(1) Duration of the seizure(2) Presence of cyanosis, breathing difficulty, or apnea(3) Level of consciousness before, during and after the seizure(4) Preceded by aura (ask the casualty)(5) Muscles involved (type of motor activity)(6) Incontinence of bladder or bowel(7) Eye movement(8) Previous history of seizures, head trauma, and/or drug or alcohol

abuse

Evacuate the casualty by ground, if possible


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Assist in Vaginal Delivery

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Given a standard fully stocked M5 Bag or Combat Medic Vest System, with an obstetrickit. You encounter a pregnant female who is in labor. IAW The Basic EMTComprehensive Prehospital Patient Care, EMT Prehospital Care

Stages of LaborFirst stage

(1) Begins with the onset of regular contractions(a) Contraction time - the span of time from the beginning of acontraction of the uterus to when the uterus relaxes

(b) Interval time - the span of time from start of onecontraction to the start of the next contraction

(2) Rupture of amniotic sac

WARNING: "Meconium staining" - amniotic fluid that is greenish orbrownish-yellow rather than clear, is an indication of possiblefetal distress during labor.

(3) Appearance of bloody show

(4) Ends with the full dilation and effacement of the cervix

NOTE: In order for a vaginal delivery to occur, the cervix must both thinout (efface) to 100% and open up (dilate) to 10cm (3-4 inches).

WARNING: There is usually time to transport the patient before deliveryduring this phase.

Second stage(1) Begins when the baby enters the birth canal

(2) Contractions become stronger

(3) Presenting part appears

(4) Ends with the birth of the baby

CAUTION: Transportation of the patient at this time should NOT BECONSIDERED. Delivery is imminent.

Third stage(1) Begins when delivery of baby is complete

(2) Ends with the delivery of the placenta and umbilical cord

Care for Normal Delivery Outside the HospitalEvaluation of the mother

(1) Ask the mother the following questions


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(a) How long have you been pregnant or expected due date?(b) How long and how often she has been having

contractions?(c) If she has had any bleeding or bloody show?

(2) Check for signs and symptoms that indicate delivery will occur beforetransport is possible

(a) Head or other presenting part is visible (crowning)(b) Mother tells you "The baby is coming", especially if she is

a multiparous woman(c) Mother feels as if she is having a bowel movement withincreasing pressure in the vaginal area

(d) Mother feels the need to push(e) Hospital is not accessible due to traffic or weather/disaster(f) Transportation will not become available before anticipated

time of delivery(3) If delivery is eminent with crowning, contact medical officer for decision to

commit to delivery on site. If delivery does not occur within 10 minutes,contact medical officer for permission to transport.

Predelivery preparation of the mother(1) Ensure the mother's privacy(2) Obtain and open emergency obstetric pack. This will provide all the

sterile supplies needed for care of the mother and infant before andafter delivery.

(3) In absence of an emergency obstetric pack medic should collect

clean sheets and towels, heavy sting or cord (shoelaces) to tie thecord, a towel or plastic bag to wrap the placenta, and clean unusedrubber gloves and eyewear

(4) Put on gloves, mask, gown, and goggles for infection controlprecaution if the conditions permit/as time allows

(5) Position the mother and prepare work space for both delivery andcare of the newborn(a) Position mother lying with knees drawn up and spread

apart. Elevate the hips with a folded blanket or pillow.(b) Create a sterile field around vaginal opening with sterile

towels or paper barriers(c) Have another individual monitoring the airway, render

assistance if she should vomit, and provide emotionalsupport

Assist in delivery of the babyEncourage mother to breathe deeply through her mouth. She may feelbetter if she pants.

When the infant's head appears during crowning, place fingers on thebony part of skull and exert slight pressure to prevent an explosivedelivery. Use caution to avoid "soft spot" (fontanelle.)


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If the amniotic sac does not break, or has not broken, use a clamp or yourfinger to puncture the sac and push it away from the infant's head andmouth as they appear

As the infant's head is being born, determine if the umbilical cord isaround the infant's neck

(a) If the umbilical cord is around the infant's neck, slip it overthe shoulder or clamp, cut, and unwrap

(b) Umbilical cord must be clamped and cut if it is wrapped tootightly around the infant's neck

After the infant's head is born, support the head, suction the mouth firstthen the nostrils two or three times with a bulb syringe if available

CAUTION: Use caution to avoid contact with the back of the mouth.

(a) Squeeze the bulb syringe before placing it in the mouth ornose

(b) Slowly release with withdrawal(c) Squeeze again to expel contents before reinserting

Continue to support the baby's head between contractions while waitingfor the rest of the body to be delivered

WARNING: DO NOT pull on the baby's head to assist with the delivery.

As the feet are born, grasp the feet. Wipe blood and mucus from mouthand nose again.

Wrap the infant in a warm blanket and place on his side, with the headslightly lower than the trunk

WARNING: Keep infant warm to prevent hypothermia, which can occurquickly.

Keep infant level with vagina until the cord is cut

Have your partner monitor and complete initial care of the newborn

The infant must be breathing on its own before clamping and cutting thecord, palpate the cord with your fingers to make sure it is no longerpulsating

(a) Use clamps or umbilical tape found in the obstetric kit(b) Apply the first clamp about 8 to 10 inches from the baby(c) Place the second clamp 2 to 3 inches below the first,

approximately 4 fingers width from infant(d) Cut the cord between the clamps or knots using sterile

surgical scissors


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CAUTION: NEVER unclasp a cord once it has been cut, or attempt toadjust a clamp once it is in place.

Observe for delivery of the placenta while preparing mother and infant fortransport

When the placenta is delivered, wrap it in a towel and put it in a plasticbag

Place sterile pad over vaginal opening, lower mother's legs, help her holdthem together. Transport mother, infant, and placenta to hospital.

Record the birth(a) Document exact time of birth on the run sheet(b) Make a double-backed tape bracelet with the time of birth

and the mother's full name. Apply to baby's wrist or ankle.

Caring for the newbornPosition, dry, wipe and wrap the newborn in a blanket and cover the head

(a) Place baby in a head-down position(b) Repeat suctioning the mouth and nose as necessary

Assessment of infant - normal findings(a) The APGAR score may be used to evaluate the newborn's

condition. Perform as soon as the infant's born and 5

minutes later.(b) Evaluating the adequacy of a newborns vital functions

immediately after birth(c) Five parameters: heart rate, respiratory effort, muscle

tone, reflex irritability, and color(d) Each parameter is given a score from 0 to 2(e) Majority of infants are vigorous and have a total score of 7

to 10Appearance - note the infant's color. Normal color is pinkwith some cyanosis of the extremities.

Pulse - determine the infant's pulse rate. The pulse rateshould be greater than 100 per minute.

Grimace - evaluate the infant's response to an irritablestimulus. The infant should cry or react vigorously.

Activity - how much is the infant moving? Infant shouldhave good motion in extremities.

Respiration effort (breathing) - the infant should bebreathing within 30 seconds after birth (breathing normalor crying)


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Stimulate newborn if not breathing(a) A gentle vigorous rubbing of the baby's back should

stimulate breathing, if that fails, snap your index fingeragainst the sole of the feet

(b) DO NOT hold the baby upside down to slap its bottom

Resuscitation of the newborn - after assessment, if signs and symptomsrequire either cardiac or pulmonary resuscitation, perform the following

steps when appropriate(a) If breathing effort is shallow, slow, or absent, provideartificial ventilations(i) 40 to 60 per minute(ii) Reassess after 30 seconds(iii) If no improvement, continue artificial ventilation

and reassessments(b) If heart rate is less than 100 beats per minute, provide

artificial ventilations(i) 40 to 60 per minute(ii) Reassess after 30 seconds(iii) If no improvement, continue artificial ventilation

and reassessments(c) If heart rate is less than 80 beats per minute and not

responding to artificial ventilations, start chestcompressions

(d) If heart rate is less than 60 beats per minute, start

compressions and artificial ventilations(i) Chest compressions in the newborn should be

delivered at a rate of 120 per minute, midsternum

(ii) Give compressions with two thumbs, fingerssupporting the back, at a depth of 1/2 to 3/4 inch

CAUTION: This is for newborns only.

(e) Color - if the infant exhibits cyanosis of the face and/ortorso with spontaneous breathing and adequate heart rate.Administer oxygen 10 to 15LPM using oxygen tubing heldas close as possible, but not directly into the infant's face.

Delivering the placentaThe placenta is normally expelled within minutes after the baby is born.Never pull on the cord to facilitate delivery.

Save the placenta in a container and place it in a plastic bag, or wrap it ina towel or paper and bring it with the mother and baby to the hospital

Emergency care of mother post-delivery - place baby to mothers breastUp to 500cc if blood loss is normal and well tolerated by the motherfollowing delivery


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The soldier medic must be aware of this loss so as not to cause unduepsychological stress on him or the new mother

If there is excessive blood loss, massage the uterus(a) Place fully extended fingers on lower abdomen above

pubis and massage lightly with a circular motion over area(b) If bleeding continues, check massage technique and

transport immediately. Provide oxygen and perform

ongoing assessment.

Regardless of estimated blood loss, if mother shows signs and symptomsof shock, treat as such and transport prior to uterine massage. Massagethe uterine fundus en route to the hospital.

Monitor for complications during laborTerms and definitions

Breech birth - delivery with the buttocks, feet, or knees appearing as thepresenting part

Premature infant- an infant weighing less than 5.5 lbs. or born beforethe 37th week of gestation

Meconium - a greenish-black to light brown, material that collects in theintestine of a fetus and forms the first stool of a newborn

Abnormal deliveries of childbirth

Premature infants ("Preemie")(a) Description

(i) An infant weighing less than 5.5 lbs. or bornbefore the 37th week of gestation

(ii) Smaller and thinner than a full-term baby(iii) The proportion of the head to the body is greater

than a full-term infant(b) Treatment and transport - same as for normal births

(i) Dry the baby thoroughly as soon as possibleafter birth

(ii) Keep warm - absence of fully developed layer offatty tissue allows rapid cooling anddevelopment of hypothermia* Wrap completely, with face exposed* Maintain temperature of room or

ambulance at 90-100o

(iii) Keep mouth and nose clear of mucus bysuctioning frequently

(iv) Provide ventilations and/or chest compressionsbased upon the baby's pulse and respiratoryeffort (see Annex F)

(v) Administer oxygen (humidified, if possible) bydirecting flow into an improvised tent over baby'sface


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(vi) Watch the umbilical cord for bleeding. Applyanother clamp or tie closer to the abdomen toprevent excessive blood loss.

(vii) Prevent contamination. Wear a gown/mask.Keep bystanders at a distance.

(viii) Handle gently while providing all care(ix) Inform hospital of premature delivery

Breech presentation(a) Description(i) Presenting part is the buttocks or feet(ii) Most common abnormal delivery

(b) Treatment and transport(i) Initiate rapid transport upon recognition of a

breech presentation(ii) Never attempt to deliver the baby by pulling on

its legs(iii) Provide high concentrations of oxygen(iv) Place the mother in a head-down position with

the pelvis elevated(v) If the body delivers, support buttocks and trunk

and prevent an explosive delivery of the head(vi) After delivery, care for the newborn, cord,

mother, and placenta as in normal delivery.

Prolapsed umbilical cord - a true emergency(a) Description

(i) Umbilical cord presents first(ii) Oxygen supply to baby is interrupted when the

cord is squeezed between the vaginal wall andthe presenting part

(iii) Commonly seen with breech deliveries or smallbabies (premature births/multiple births)

(b) Treatment and transport(i) Perform initial assessment(ii) Place mother with her head down and elevate

her hips with a blanket or pillow, this will lessenpressure on the birth canal

(iii) Provide a high concentration of oxygen(iv) Gently push on the presenting part to keep

pressure off cord, by inserting several fingers ofyour gloved hand into the vagina. Maintain thisposition until relieved by the physician at themedical treatment facility.

(v) Check the cord for pulses and keep it warm witha towel moistened with sterile saline andwrapped again with a dry towel

(vi) DO NOT attempt to push the cord back insidethe mother

(vii) Transport immediately to a medical facility


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(viii) Have your partner obtain baseline vital signs,AMPLE history, and physical exam en route tothe hospital, if possible

Limb presentation(a) Description - arm or leg presents first(b) Foot is the most common in a breach presentation(c) Limb presentation cannot be delivered in the prehospital

setting(d) Treatment and transport(i) Place mother in a head down position with hips

elevated(ii) Administer a high concentration of oxygen(iii) DO NOT attempt to place the limb back into the

vagina(iv) Transport immediately to a medical facility

Multiple birth(a) Description - more than one infant is being born (e.g.,

twins, triplets)(b) Treatment and transport

(i) Assist as in a single delivery(ii) Clamp and cut the cord of first baby(iii) Note time of first birth(iv) Assist with subsequent births, cut and clamp

each cord. Note the time of each birth.(v) Make certain to identify each child and order of

birth (1 and 2 or A and B)(vi) Provide care for each infant, mother, umbilical

cord, and placenta as with a single delivery

Meconium staining(a) Description

(i) Greenish or brownish-yellow amniotic fluid. Aresult of fecal material released from the baby'sbowels before birth.

(ii) Occurs when the infant is distressed due to cordcompression, trauma, or other complicationswhile inside the amniotic sac

CAUTION: Appearance of meconium in amniotic fluid is a sign that theinfant has a potentially serious problem. Aspiration ofmeconium by the infant during delivery can cause severerespiratory complications.

(b) Treatment and transport(i) Suction the baby's mouth, then nose BEFORE

stimulating the baby to breathe. This is to avoidaspiration of amniotic fluid with meconiumparticles.


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(ii) Continue to monitor the airway(iii) Transport immediately(iv) Notify hospital of the presence of meconium in

the fluidPredelivery Emergencies

Miscarriage/spontaneous abortionFetus and placenta may deliver before the 20th week of pregnancy

(a) Signs and symptoms

(i) Moderate to severe vaginal bleeding(ii) Abnormal cramping(iii) Discharge of tissue, blood, and/or blood clots

from the vagina(b) Emergency care steps

(i) Perform initial assessment(ii) Obtain AMPLE history and baseline vital signs(iii) Initiate and maintain IV with Normal Saline(iv) Treat for shock if indicated(v) Administer high concentration oxygen(vi) Place sanitary pad over the vagina. Save all

used pads.(vii) Save all expelled tissue(viii) Provide emotional support(ix) Transport immediately

Ectopic Pregnancy

(a) 95% of all ectopic pregnancies occurs in a fallopian tube

(b) Usually referred to as a tubal pregnancy

(c) Most likely to occur when the fallopian tube is scarred from

infection (PID) or previous abdominal/gynecological

surgeries

(d) Signs and symptoms

(i) Abdominal pain initially localized to one side or

the other of the lower abdomen

(ii) Initially pain is crampy and intermittent in

nature

(iii) As pregnancy progresses, the fallopian tube

ruptures and pain becomes constant and diffuse

throughout the abdomen

(iv) Patient may experience shoulder pain which

suggests a large hemoperitoneum

(v) Patient may or may not have vaginal bleeding

(vi) Patient usually has a history of amenorrhea

(e) Emergency care and treatment

(i) Maintain airway


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(ii) Administer oxygen

(iii) Keep patient supine

(iv) Initiate a large bore IV and administer IV fluids

(v) Keep NPO (nothing by mouth)

(vi) Transport immediately to definitive care facility

Pre-eclampsia (toxemia of pregnancy)

(a) Signs and symptoms(i) Hypertension(ii) Proteinuria - protein in the urine(iii) Elevated blood pressure(iv) Excessive weight gain(v) Swelling (edema) of the face, hands, ankles,

and feet(b) Emergency care steps

(i) Notify medical officer immediately(ii) Perform initial assessment(iii) Obtain SAMPLE history and baseline vital signs(iv) Treatment based on signs and symptoms(v) Transport patient on her left side

Eclampsia(a) Signs and Symptoms

(i) Headaches(ii) Visual disturbances(iii) Epigastric pain(iv) Massive swelling (edema) especially of the face

and hands(v) Proteinuria (protein in the urine)(vi) Seizures - occurrence of seizures clearly marks

transition of pre-eclampsia to eclampsia(b) Emergency care and treatment

(i) Position on left side. Keep patient quiet and in adarkened room, if possible

(ii) Administer high flow oxygen(iii) Initiate and maintain intravenous line(iv) Transport to hospital as gently and quickly as

possible(v) Anticipate seizure activity. Have suction readily

available.

(vi) Pharmacological interventions as directed byMD/PA

Ante partum Hemorrhage (bleeding before delivery)(a) Three main causes

(i) Abruptio placenta - premature separation of theplacenta from the wall of the uterus during thelast trimester of pregnancy. Patient willexperience sudden onset of severe abdominal


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pain with or without vaginal bleeding. Fetalmovement/fetal heart tones are usually absent.The abdomen will be tender and the uterus rigidto palpation.

(ii) Placenta previa - painless vaginal bleeding.Usually bright red. Occurs as the cervix beginsto dilate in preparation for delivery and theplacenta covers all or part of the cervical canal.

Fetal movement continues and fetal heart tonesare audible. Uterus is soft and non-tender.(iii) Uterine rupture - usually occurs during labor.

Women at risk are multiparous or have had aprevious c-section. Vaginal bleeding may ormay not be present. Contractions will havelessened or stopped. Patient will exhibit obvioussigns of shock.

(b) Emergency care and management(i) Regardless of cause of third trimester bleeding,

management and treatment are the same.(ii) Position on left side(iii) Administer high flow oxygen(iv) Initiate and maintain at least two large-bore IV's(v) Treat for shock(vi) Notify MD/PA Immediately(vii) Evacuate/transport to definitive care facility

Trauma in pregnancy(a) Three major causes

(i) Motor vehicle crashes(ii) Falls(iii) Penetrating injuries (i.e. gun shot wounds)

(b) Anatomic changes of pregnancy(i) Compression of abdominal contents into upper

abdomen results in a higher incidence ofabdominal trauma in association with chesttrauma

(ii) Bladder is displaced upward and forward so it isoutside the pelvic cavity and is at increased riskfor injury

(iii) The obviously enlarged uterus is at risk forinjury/rupture

(c) Physiologic changes of pregnancy(i) Vascular volume increases to support the

perfusion of two circulations (patient and fetus)(ii) Increase in cardiac output to pump increased

volume - resting heart rate increases to 15-20BPM's

(iii) Redistribution of blood volume with as much asa tenfold increase in blood flow to the pelvicregion


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(iv) Respiratory changes include an increased needfor oxygen due to a higher basal metabolism -increased minute volume

(v) Tidal volume increases along with minutevolume to rid the body of the increased CO2from the patient and fetus

(vi) All of the physiologic changes make it difficult toassess for signs and symptoms of shock and to

adequately ventilate the patient(d) Emergency care and management(i) Treat the mother first(ii) Maintain adequate airway(iii) Administer high flow 02 - oxygen needs are 10 -

20% higher than normal(iv) Assist with ventilations as needed - remember to

provide higher minute volume(v) Control external bleeding(vi) Position on left side - lying on the left side will

shift the weight of gravid (pregnant) uterus offthe vena cava. If immobilized on backboard, tiltboard 30 degrees to the left.

(vii) Initiate and maintain IV(viii) Transport/evacuate to definitive care facility

Identify additional gynecological emergencies

Ectopic pregnancy(1) Assessment findings

(a) Acute abdominal pain(b) Vaginal bleeding(c) Rapid and weak pulse(d) Low blood pressure

(2) Notify MD/PA(3) Prepare for immediate transport(4) Maintain ABC's(5) Administer high flow 02(6) Initiate and maintain IV with Normal Saline(7) Reassess continuously


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Perform Medical Screening

21


Given a patient medical record, immunization record, supplies, and equipment at EchelonII and below, provide soldier readiness processing for a company size element. Evaluatea patient who presents for an Ambulatory Medical Visit (Sick Call). Performed soldierreadiness processing in support of unit deployment. Evaluated a patient who presentsfor an Ambulatory Medical Visit.

Screen medical records for accuracy and completeness

Primary goal of the medical screener is to provide timely, quality care foractive duty personnel with minor medical conditions(1) Do not function as independent providers(2) Work under the direct supervision of a medical officer who is

responsible for the care the medic provides

The following guidelines must be followed:(1) The SOAP format must be used when evaluating a patient(2) Consult with the supervising medical officer prior to the patient

leaving the treatment facility(3) Know your limitations and immediately refer to an MD/PA any patient

with one of the following conditions:(a) Febrile illness with temperature exceeding 101 F(b) Acute distress such as, breathing difficulties, chest pain,

acute abdominal pain, suspected fractures, lacerations,etc.

(c) Altered mental status(d) Unexplained pulse above 120 per minute(e) Unexplained respiratory rate above 24 or less then 8 per

minute(f) Diastolic blood pressure over 100 mm Hg systolic BP less

than 90 mmHg

Soldier medics responsibilities during medical screening procedures(sick call)(1) Validate identification of soldier(2) Gather sick slip and review(3) Sign patient in and pull soldier's medical record (Initiate a

replacement record if required)(4) Complete vital signs and document on appropriate form (e.g. DA

Form 5181, SF 600, and DD Form 689

(5) Check for medical profile(s) (temporary or permanent)(6) Check Over 40 Physical (as required)(7) Check for eyeglasses and protective mask inserts (as required)(8) Check for DNA sample(9) Check for Medical Warning Tags (DA Form 3365)(10) Refer to medical authority as required(11) Screen individual IAW APC, Algorithm-Directed Troop Medical Care,

HSC Pam 40-7-21, for soldier's chief complaint


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(12) Follow algorithm protocol for disposition and/or treatment andannotate on appropriate form

(13) Sign individual out of BAS and follow appropriate disposition afterscreened by medic or PA evaluation

(14) Clean and set up screening area for next individual reporting to sickcall

(15) Secure medical record

Screen immunization records for accuracy and completeness

Screen immunization records(1) Validate identification of soldier(2) Ensure all immunizations are current on PHS 731 (Shot Record)

(a) Refer to medical record if shot record is not available(b) Inquire regarding allergic reactions(c) Check for Medical Warning Tags(d) Refer to immunization site if immunizations are required

(3) Return immunization record to soldier(4) Secure medical record

Shot Call(1) Persons who administer vaccinations must be trained in:

(a) Management of anaphylaxis(b) Immunization procedures(b) Proper use and maintenance of equipment(c) Indications and contraindications for each vaccine(d) Storage requirements(e) Management and reporting of adverse reactions(f) Immunization record maintenance

(2) Patients who report to shot call should be:(a) Screened for chronic/acute illness(b) Screened for pregnancy(c) Screened for medications that might interact with

immunizations(d) Screened for allergies(e) Offer Tylenol to minimize local and systemic shot reactions(f) Observed for at least 20 minutes after administration for

symptoms of anaphylaxis

Screen for personnel / administrative matters

S-1 personnel (administration) center will screen these records

Validate / inspect Identification Card (DD Form 2A)

Validate / inspect Geneva Conventions ID Card (DD Form 1934)(asrequired)

Refer for new card(s) as required


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Check Identification tags (2 sets) for accuracy

Screen Dental Records

Review date of last dental examination(1) Ensure Class 1 or 2(2) Ensure Dental X-rays (Panorex) is present and up to date

Refer to Dental authority as required

Ask and record the following Medical History information on theprescribed form

Purpose of the Chronological Medical Record(1) To improve communication among all those caring for the patient(2) To display the assessment, problems and plans in an organized

format to facilitate the care of the patient and for use in record reviewand quality control

Ask and record medical history information(1) Identifying data(2) Chief complaint:

(a) Concise statement(b) Primary reason the patient seeks help(c) Use patient's own words

(3) Present illness:(a) State of health prior to onset of illness(b) Nature and circumstances of onset(c) Location and nature of pain or discomfort(d) Progression(e) Treatment received and its effect

(4) Past history:(a) Childhood diseases(b) Previous illnesses and injuries(c) Previous hospitalization and surgery

(5) Family history:(a) History of chronic illness(b) Familial illness (sickle cell)

(6) Social history:(a) Marital status

(b) Occupational data(c) Habits (tobacco, alcohol, drugs)

Use the SOAP Note Format(1) S: SUBJECTIVE DATA: what the patient tells you(2) O: OBJECTIVE - physical findings and lab/ X-ray(3) A.: ASSESSMENT - Your interpretation of the patients condition(4) P: PLAN


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Perform a patient examination

Determine what is wrong with the patient based on patient's ownstatements regarding his specific condition.

Determine the chief complaint based on the patient's own statements:Focused examination based on chief complaint

The S.O.A.P. (E. R.) method is the only accepted method of medicalrecord entries for the military(1) S: (subjective) - What the patient tells you(2) O: (objective) - Physical findings of the exam(3) A: (assessment) - Your interpretation of the patients condition(4) P: (plan) - Includes the following

(a) Therapeutic treatment: includes use of meds, use ofbandages, etc.

(b) Additional diagnostic procedures: any test that still mightbe needed

(5) E: (patient education) - special instructions, handouts, use ofmedications, side effects, etc.

(6) R: (return to clinic) - when and under what circumstances to return.

Components of the patient examination (SOAP note)(1) Medical History - Gives you an idea of the patients problem before

you start physical exam

(a) Biographic data(b) Chief complaint

(i) This is the reason for the patients visit(ii) Use direct quotes from patient(iii) Avoid diagnostic terms

(c) Observation: begins as soon as the patient walks throughthe door

(d) Listening: listen carefully. This will help you get anaccurate diagnosis of the problem

(e) Open ended questions: help you to get more complete andaccurate information

(f) Provider obstacles: your attitude or predetermination mayprevent you from making an accurate judgment

(g) Patient obstacles: the patient has many obstacles toovercome. Patients must have confidence in you.

(2) History of present illness/injury (HPI)(a) Duration: when the illness/injury started

(b) Character: use the patients words to note character ofpain

(c) Location: have the patient explain, then have them point itout

(d) Exacerbation or remission: what makes it better or worseand is it constant or does it vary in intensity

(e) Positional pain: does the pain vary with the change of thepatients position.


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(f) Medications/allergies: note any medications whether overthe counter or not. Do the medications relate to theproblem? Take note of the patients allergies. Do not relyon the patients health record or SF 600.

(g) Pertinent facts: facts that lead you to your diagnosis.Usually consist of classical signs and/or symptoms.

(3) Another method to take a medical history is by using the key phrase"SAMPLE PQRST"

S: SymptomsA: AllergiesM: Medicine takenP: Past history of similar eventsL: Last mealE: Events leading up to illness or injuryP: Provocation/Position - what brought symptoms on, where

is pain locatedQ: Quality - sharp, dull, crushing etc.R: Radiation - does pain travelS: Severity/Symptoms Associated with - on scale of 1 to 10,

what other symptoms occurT: Timing/Triggers - occasional, constant, intermittent, only

when I do this (Activities, food)

(4) Past History (PH)(a) Other significant illnesses

(b) Prior admissions(c) History of major trauma(d) Surgery(e) Childhood illnesses(f) Neurological history

(5) Family History(a) This is the pertinent history of diseases of the family within

the patients bloodline.(b) Any disease traced through the family is important. If no

history found, note it on SF600(6) Social History (SH)

(a) Drugs, recreational(b) ETOH(c) Tobacco(d) Over the counter medications

Disposition Plan

Treat illness or injury within prescribed "Ambulatory Patient Care" (HSCPAM 40-7-21) Algorithms

Definition of algorithmA step by step procedure for solving a problem

Purposes


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(1) Systematic approach to screening patients(2) Guidance for minimally trained medical personnel to provide a logical

conclusion when dealing with medical problems within the limits ofhis/her training

Algorithm Dispositions Category(1) PHYSICIAN STAT/Category I - medical problem (Emergency) exist

that may be life threatening

(a) Requires immediate attention of a physician that canhandle circumstance(b) Notify the physician assistant and the senior medic of

a Category I patient if a physician is not present.(a) First aid should be initiated and ambulance transportation

arranged if MTF is outside of hospital(2) PA STAT/Category II - medical problem may exists that may

develop into a life threatening condition if not evaluated on a prioritybasis by a physician, PA

(3) PA TODAY/Category III - medical condition exists which requiresPA evaluation(a) Patient will be screened IAW APC-21 algorithm and then

sent to PA(b) Physician or PA will make final disposition

(4) SELF-CARE PROTOCOL/Category IV--condition exists that can betaken care of by individual(a) Instructions and/or medications are offered to individual

per algorithm protocol(b) Individual or screener may elect to override self-care

protocol and have the patient seen by medical officer

NOTE: Overriding this protocol usually depends on appearance of individualor if medical problem is chronic and self-care has already beenattempted without results.

(5) HOSPITAL CLINIC REFERRAL/Category V - medical conditionexists that requires evaluation by a specialty clinic (e.g. podiatry,OB/GYN, allergy)(a) Medical officer at MTF must make referral(b) PA may want to attempt treatment care plan at MTF level if

qualified personnel and resources are available

Steps in screening patient complaint(1) Locate category of chief complaint in table of contents.

(a) Category of complaint, EXAMPLE - Ear, Nose, andThroat (ENT) Complaints

(b) Complaint, EXAMPLE - sore Throat(c) Number and page, EXAMPLE - A-1, 16

(2) Review preceding page of algorithm prior to, during, and after patientscreening(a) EXAMPLE - important information on the algorithm


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(b) EXAMPLE - treatment protocol, for instructions andmedications to provide patient after screening has beencompleted

(3) Begin with Block 1 of algorithm and follow arrows depending onpatient's response(a) EXAMPLE - is there a history of recent throat or neck

trauma?(b) EXAMPLE - if NO, (go to block 3)

(c) EXAMPLE - can the patient touch chin to chest?(d) EXAMPLE - if NO, (go to block 4)(e) EXAMPLE - is temperature 100 F or higher, or is the

patient unable to swallow? (Determine ability to swallow byobserving the patient)

(f) EXAMPLE - if NO, (Category III)(4) If disposition is a Category IV, refer to preceding page for treatment

protocol.(a) EXAMPLE - Block 6, Can the patient clear both ears?(b) EXAMPLE - if YES, (Category IV, Treatment Protocol A-1

(6)(c) Follow protocol for medication and patient instructions

(5) If disposition is an associated complaint, refer to complaint algorithmand begin at block 1 with new complaint.(a) EXAMPLE - Block 6, Can the patient clear both ears?(b) EXAMPLE - if NO, (Screen for Ear Pain, Discomfort, or

Drainage, A-2).

(6) Refer to PA Today, Category III disposition if:(a) Complaint not on list(b) Patient has already tried the treatment protocol without

relief(c) Patient will not accept treatment protocol

Information needed in the DD Form 689(1) MTF personnel are responsible for making sure DD Form 689 blocks

1 through 9 are correctly filled out by a soldier prior to beingevaluated by a screener

(2) MTF personnel may fill out a sick slip for a soldier if he is unable todue injury, illness, or reporting directly to the MTF in the event of anemergency

(3) All military forms will be filled out in black ink(4) Block 1 - box checked by individual that best fits remarks section

(block 8)(a) Illness--acute or chronic, (e.g. common cold symptoms, athletes

foot, nausea, vomiting, etc.)(b) Injury--acute (e.g. direct/indirect trauma within 24 to 48 hours)

(5) Block 2 - date(6) Block 3 - name (e.g. complete last, first, middle initial, Doe, Johnny

E.)(7) Block 4 - service number. SSN (e.g. complete 9 digits, 000-11-0000)(8) Block 5 - grade/rank (e.g. pay grade, E-1, etc.)


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(9) Block 6 - organization and Station (e.g. C Co. 232D MedicalBattalion, Ft. Sam Houston, TX 78234)

(10) Block 7 - in line of duty (e.g. yes/no depending on circumstances)(a) Company or unit commander ONLY fills out this block

when injury occurs(b) Often left blank unless negligence is suspected (e.g.

soldier was intoxicated at time of injury, or was not athis/her appointed place of duty at time of injury etc.)

(11) Block 8 - remarks (e.g. sore throat and cough x4 days; right anklepain, difficulty walking due to injury x24 hrs.)(a) Filled out by individual(b) Includes chief complaint (c/o). (e.g. sore throat; right ankle

pain)(c) Associated illnesses/pain. (e.g. cough; difficulty walking)(d)

How long? problem(s) have existed or wheninjury occurred. (e.g. x4 days; x24 Hrs)

(12) Block 9 - signature of unit commander.(a) First line supervisor or person who is in charge of quarters

(CQ) may sign for unit commander (per unit SOP)(b) Individual signing the sick call slip must be in individual's

immediate chain of command(13) Block 10 - in line of duty (e.g. yes/no or left blank).(14) Block 11 - disposition of patient.(15) Block 12 - remarks (e.g. Quarters x24 Hrs, return in A.M. for follow

up or Profiling e.g. no running or marching x5 days)

(a) Remarks reflect box checked in block 11(b) Also indicates:

(i) Soldier's arrival time at MTF(ii) Soldier's disposition(iii) Time of release back to unit

(16) Block 13--signature of medical officerONLY(17) Disposition of DD Form 689

(a) DD Form 689 is returned to individual after medicalevaluation has been completed

(b) Soldier returns original sick slip to first line supervisor orper unit SOP

(c) Soldier keeps copy of sick slip if quarters or profile given


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Immunization and Chemoprophylaxis

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Given an order to deploy, ensure proper immunization and chemoprophylaxis IAW AR40-562.

Personnel subject to immunizations and required shots

All active duty personnel are subject to immunizations

Specific Requirements

(1) Anthrax - not being administered at present(a) Dosage Schedule

(i) Full immunity requires six doses administered at0, 2, and 4 weeks, and at 6, 12, and 18 months,to complete the primary series. This schedule isthe only schedule approved by the FDA at thistime. Annual boosters are required.

(ii) Doses of the vaccine should not be administeredon a compressed or accelerated schedule (forexample, shorter intervals between doses ormore doses than required).

(b) Medical exemptions can only be granted by a medicalofficer (MD/PA)

(c) Adverse Events(i) Localized injection site reactions-redness, pain(ii) Serious adverse reactions are rare

(2) Cholera(a) Cholera vaccine is not administered routinely(b) Only administered to military personnel, upon travel or

deployment to countries requiring cholera vaccination as acondition for entry

(c) Adverse Events:(i) Pain at injection site, mild systemic complaints,

and temperature > 37.7 C(ii) Local reaction may be accompanied by fever,

malaise, and headache(iii) Serious reactions, including neurologic

reactions, after cholera vaccination areextremely rare

(3) Hepatitis A(a) Use Hepatitis A vaccine and immune globulin (IG)

according to Army Command Immunization Program(ACIP) and Service - specific guidance

(b) Adverse events: Rare(4) Hepatitis B

(a) Given to health care workers and soldiers PCSing toKorea.


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(b) Adverse Events: Pain at injection site, mild systemiccomplaints, and temperature > 37.7 C

(5) Influenza(a) All active duty and reserve military personnel entering

active duty for periods in excess of 30 days are immunizedagainst influenza soon after entry on active duty

(b) The vaccine is provided to all health care providers andothers considered to be at high risk for influenza infection

(c) Adverse Events: Local reactions, fever/malaise (common)severe allergic reactions, and neurological reactions (rare)(6) Japanese B Encephalitis (JE)

(a) Specific guidance on indication for use and schedule ofimmunization in military populations is provided by theeach service

(b) Adverse Events: Fever, headache, myalgias, malaise(common). General urticaria, angioedema, respiratorydistress, and anaphylaxis (rare).

(7) Measles, Mumps, and Rubella (MMR)(a) Measles and rubella are administered to all recruits

regardless of prior history(b) Mumps or MMR vaccine is administered to persons

considered to be mumps susceptible. Writtendocumentation of physician diagnosed mumps or adocumented history of prior receipt of live virus mumpsvaccine or MMR vaccine is adequate evidence of

immunity.(c) Adverse Events: Low grade fever, parotitis, rash, pruritis

(mild), deafness (rare)(8) Meningococcus

(a) Meningococcal vaccine is administered on a one-timebasis to recruits.

(b) Adverse Events-rare(9) Plague

(a) There are no requirements for routine immunization.Plague vaccine is administered to soldiers who are likely tobe assigned to areas where the risk of endemictransmission or other exposure is high.

(b) The addition of antibiotic prophylaxis is recommended forsuch situations.

(c) Adverse Events: General malaise, headache, fever, mildlymphadenopathy, and/or erythema, and induration at theinjection site

(10) Polio(a) A single dose of trivalent OPV is administered to all

enlisted recruits. Officer candidates, ROTC cadets, andother Reserve Components on initial active duty fortraining receive a single dose of OPV unless prior boosterimmunization as an adult is documented.

(c) Booster doses of OPV are not routinely administered(d) Adverse Events


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(i) Paralytic poliomyelitis: more likely inimmunodeficient persons, no procedureavailable for identifying persons at risk ofparalytic disease (rare).

(11) Rabies(a) Preexposure Series. Rabies vaccine is administered to

personnel with a high risk of exposure (animal handlers;certain laboratory, field, and security personnel; and

personnel frequently exposed to potentially rabid animalsin a nonoccupational or recreational setting).(b) Post exposure Series. Rabies vaccine and rabies immune

globulin (RIG) administration will be coordinated withappropriate medical authorities following current ACIPrecommendations.

(c) Adverse Events: Anaphylaxis (rare)(12) Smallpox

(a) This vaccine is administered only under the authority of theImmunization Program for Biological Warfare Defense

(b) Adverse events: Person can become infected with thesmallpox virus.

(13) Tetanus-Diphtheria(a) A primary series of tetanus-diphtheria (Td) toxoid is

initiated for all recruits lacking a reliable history of priorimmunization. Individuals with previous history of Tdimmunization receive a booster dose upon entry to active

duty and every 5-10 years thereafter.(b) Adverse events

(i) Local reactions (erythema, induration)(ii) Nodule at injection site(iii) Fever and systemic symptoms uncommon

(14) Typhoid(a) Typhoid vaccine is administered to alert forces and

personnel deploying to endemic areas. Either oral orintramuscular vaccine is used.

(b) Adverse Events(i) Local reactions maybe accompanied by fever,

malaise, and headache (common)(ii) Nausea(iii) Abdominal cramps(iv) Vomiting(v) Skin rash(vi) Urticaria

(15) Yellow Fever(a) Yellow fever immunization is required for all alert forces,

active duty personnel or Reserve Components traveling toyellow fever endemic areas.

(b) Adverse events:(i) Mild headache, myalgia, low grade fever, other

minor symptoms


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(ii) Immediate hypersensitivity reactions: rash,urticaria, and asthma. Uncommon and occurperiodically among people with a history of eggallergies

Chemoprophylactic Requirements

(1) Command medical officers review indications for use and potentialadverse effects of specific chemoprophylactic medications prior touse. Current ACIP(Advisory Committee on Immunization Practices)or Control of Communicable Disease Manual recommendations andconsultation with the relevant preventive medicine authority arefollowed for the use of chemoprophylactic agents for the followingdiseases which have historically been shown to be of militarysignificance:(a) Influenza(b) Meningococcal disease(c) Leptospirosis(d) Plague(e) Scrub typhus(f) Traveler's diarrhea

Malaria

(1) Comprehensive malaria prevention counseling includes mosquitoavoidance and personal protective measures (clothing, repellents,bednetting, etc.). Chemoprophylaxis is provided to military andcivilian personnel considered to be at risk of contracting malaria.Specific chemoprophylactic regimens are determined by each of theservices based on degree and length of exposure and theprevalence of drug resistance strains of Plasmodia in the area(s) oftravel.

Group A Streptococcal Disease

(1) Each service develops policies for surveillance and prophylaxis ofstreptococcal disease at recruit centers

Pre-administration Screening

Medical record screening

(1) What immunizations are required for this individual?(a) Routine immunizations are identified in AR 40-562 and

local policy(b) Additional requirements specific for deployment:

(i) Based on disease prevalence in specificgeographic regions


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(ii) Determined by Preventive Medicine usingFederal, Department of Defense, and otherrelevant sources of information

(2) Current immunization status:(a) What has been given?(b) When?(c) Initial series completed?(d) Are boosters current?

(3) What immunizations are needed, if any, to meet currentupdate/deployment requirements?(4) If pre-deployment, is there time to administer all required vaccine

series/boosters before date of departure? If not, is an exception topolicy needed?

(5) Does the medical record reflect any contraindications forimmunization?

Patient screening

(1) It isYOUR responsibility to ask the patient about allergies,pregnancy, or current illness BEFORE administering the vaccine

(2) Refer patients with any risk factors to the medical officer fordisposition

Vaccine Handling, Administrative, and Patient Care Procedures

Vaccine handling

(1) Pre-immunization(a) Check expiration date/time

(b) Evaluate for potential mishandling or contamination(i) Proper storage temperature

* Refrigerated vaccines - 35.6 to 46.4oF

* Frozen vaccines - 0 to 50 F or asdirected by manufacturer.

(ii) Evidence of bacterial growth(iii) Color change/clarity of solution

(2) Post-immunization(i) Store partially used vials at proper temperature(ii) All live virus vaccine containers should be handled as

infectious waste and disposed in biohazard containers tobe burned, boiled, or autoclaved, follow local SOP.

Administrative procedures

(1) Pre-immunization(a) Screen medical record


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(b) Select correct equipment (needles and syringes) forimmunizations to be administered

(c) Document vaccine lot number and other identifyinginformation as required by local SOP

(2) Post-immunization(a) Document all vaccines given in patient medical record (SF

601) IAW local SOP(b) Record immunizations in individual shot record (PHS 731)

(c) Record any reactions or side effects

Patient care procedures

(1) Pre-immunization(a) Ask about contraindications for immunization (allergies,

pregnancy, illness etc.)(b) Implement appropriate infection control procedures(c) Explain procedure to patient(d) Position patient and administer required immunizations

(2) Post-immunization(a) Inform patient when he is to return for next injection in

series/booster(b) Instruct patient to wait in facility for observation for 20

minutes (or IAW local SOP)(c) Assure patient is evaluated during and at end of

designated waiting period for signs of an adverse reaction

Reactions and possible side effects

Vaccine components can cause allergic reactions in some recipients

Prior to the administration of any immunizing agents, determine if theindividual has previously shown any adverse reactions to a specificagent or vaccine component

Vaccine components that can cause reactions include:

(1) Vaccine antigen (a substance that causes the formation of anantibody)

(2) Animal proteins(3) Antibiotics (e.g., penicillin or penicillin derivatives)

(4) Preservatives (e.g., thimerosal, a mercurial compound)(5) Stabilizers

The most common animal protein allergen is egg protein

Vaccination during pregnancy

(1) Ideally, all immunizations should precede pregnancy.(2) Live virus vaccines are contraindicated (Yellow fever, MMR, OPV)


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(3) Refer pregnant soldiers to medical officer for disposition.(4) Breast-feeding - Refer soldier to the medical officer (MD, PA) for

disposition

Vaccination with significant illness

(1) Persons should not be vaccinated if they have moderate or severefebrile illness (usually 101o F or higher, per local SOP)

(2) Persons should be vaccinated as soon as they recover from theacute phase of the illness(3) Minor illnesses, such as diarrhea, mild upper-respiratory infection

with or without low-grade fever, or other low-grade febrile illness arenot contraindicated to vaccination

HIV positive status due to compromised immune system, vaccines shouldnot be administered to any patient who has tested positive for HIV, unlessspecifically ordered by the attending physician with knowledge of the diagnosis

Multiple vaccines

(1) Contraindicated Combinations/Cautions(a) Do not administer cholera, plague, and/or typhoid vaccines

together unless deploying immediately(b) Multiple live virus vaccines may be given the same day. IF

THEY ARE NOT GIVEN THE SAME DAY, they must be

separated by 30 days. Live virus vaccines are: oral polio,yellow fever, measles, mumps, rubella, and adenovirus.

(c) Gamma globulin (immune serum globulin) and MMR mustbe given at least 14 days apart; if closer together, MMRmay be partially or completely ineffective in protectingagainst disease. If closer administration is unavoidable,MMR must be repeated after three months. Gammaglobulin administration does not reduce effectiveness ofinactivated vaccines.

(d) A PPD TB test and live vaccines may be given the sameday. IF NOT GIVEN THE SAME DAY, the TB test must bedeferred for 6 weeks after the live vaccine is given, toprevent a false negative result from the TB test.

(2) No more than one vaccine should be administered in any oneanatomical site.

Documentation

DHHS Form PHS 731 is prepared for each member of the Armed Forcesand for nonmilitary personnel.

(1) Valid certificates of immunization for international travel andquarantine purposes.


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(2) Remains in the custody of the individual who is responsible for itssafekeeping and for keeping it in his or her possession whenperforming international travel.

(3) Entries based on prior official records have the following statementadded: "Transcribed from official U.S. Department of Defenserecords."

(4) Obtained through normal publication supply channels. The DODImmunization Stamp is available through medical supply channels.

National vaccine injury compensation program

(1) Information is recorded on PHS Form 731, medical record and onthe clinic log or equivalent computer data base. Informationincludes, name, sponsor's SSN, date of administration, type ofvaccine, manufacturer, lot number, and the name, address, and titleof person administering the vaccine.

(2) In addition, all health care providers who administer any vaccinecontaining diphtheria, tetanus, pertussis, measles, mumps, rubella,or polio to either children or adults must provide a copy of the mostrecent relevant vaccine information materials provided by the DHHS

Issuance of DHHS Form PHS 731 to Military Personnel

(1) At the time of initial immunization of a person entering militaryservices, DHHS Form PH 731 and SF 601, Health Records-

Immunization Records, are initiated as outlined below. Writtenstatements from civilian physicians attesting to immunization withapproved vaccines, and providing dates and dosages, are acceptedas evidence of immunization. Such information is transcribed toofficial records. Immunizations are recorded on the cited forms, andthe forms are maintained as follows.

(2) Army, Navy, and Marine Corps. SF 601 is prepared in accordancewith AR 40-66, Medical Records and Quality AssuranceAdministration, And Chapter 16, NAVMED P-107, Manual of theMedical Department, U.S. Navy. When prepared, SF 601 and DHHSForm 731 contain the SSN as identifying data

Issuance of DHHS Form PHS 731 to Nonmilitary Personnel

(1) At the time of initial immunization of nonmilitary personnel, entriesare made on DHHS Form PHS 731, which is retained by theindividual. All subsequent immunizations are recorded on this formwhich can be presented as an official record of immunizationsreceived. In addition to DHHS Form PHS 731, SF 601 (Army, Navyand Marine Corps) or SF 600 (Air Force) is prepared andpermanently maintained for each individual. Individuals preparingthe DHHS Form PHS 731 and SF 601(600) ensure appropriateentries are recorded on both forms and both forms are current andagree with one another.


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Specimen Collection

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Stool specimens

General principles(1) Reason - stool specimen yields information about the patient related

to the functioning of the gastrointestinal system and its accessoryorgans (See C191W026, Treat Gastrointestinal Symptoms)

(2) Explain the reason for the test to the patient(3) The best time of day to collect a stool specimen is soon after

breakfast(4) Patient should be instructed that a stool specimen is to be saved(5) Patient should be instructed to notify the soldier medic as soon as

there is an urge to defecate(6) Give the bedpan to the patient when they are ready(7) Use tongue blades and wear gloves when transferring the stool

specimen to the specimen cup(8) Some specimens must be kept warm to keep any parasites alive

until the specimen is examined in the laboratory(9) Always label the specimen container with the patient's name, SSN

and all pertinent information(10) Always send an appropriate lab slip with the container

Guaiac test

(1) Purpose - to ascertain the presence of occult blood that is not visible(2) Each method of testing has a specific procedure that must be

followed in order to obtain accurate results (i.e. food restrictions andnumber of days to collect smear)

(3) Manufacturer's instructions or hospital procedure manual should beconsulted for specifics

Urine specimens

General principles(1) Urinalysis is the laboratory examination of a urine specimen.

Analysis of the urine is a common way of securing data about aperson's health state.

(2) The soldier medic is responsible for instructing the patient abouturine collection techniques or for obtaining specimen from the patient

(3) A cooperative patient can be instructed to put specimen into a clean

or, in some instances, a sterile container. Care should be taken thatthe outside of the container is not contaminated.

NOTE: Precautions similar to those when handling blood are appropriatewith all body fluids.

Mid-stream (clean-catch)(1) Reason for obtaining a mid-stream:


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(a) Obtain a sample that has been in the bladder an extendedperiod of time

(b) Provide accurate information of the function of the kidneysthe presents of pathogenic organisms, and the excretion ofelectrolytes that are normally use for normal bodyfunctions (i.e., potassium)

(2) Patient voids a little urine, which is discarded; the specimen iscollected during mid-stream, and the last urine in the bladder is also

discarded(3) Procedure(a) Wear gloves(b) For the female

(i) Spread the labia well, and keep them apart untilthe specimen is obtained.

(ii) Clean the area at the external meatus withsterile gauze or cotton balls and antiseptic soapand water.* Move the gauze or cotton balls from

the meatus toward the anus* Use one piece of gauze or one

cotton ball for each stroke(iii) Have the patient void about 30 cc then discard

this urine(iv) Position the sterile specimen container near but

not touching the meatus and ask them to void

forcibly if she is lying down. This preventscollecting a specimen that has dribbled downacross the perineal area.

(c) For the male(i) Retract the foreskin to expose the glans penis in

the uncircumcised male patient(ii) Clean the area of the external meatus with

sterile gauze or cotton balls and antiseptic soapand water* Move gauze or cotton ball in a circular

manner at the meatus, and movedown the shaft of the penis a fewinches

* Use one piece of gauze or one cottonball for each stroke

(iii) Have the patient void about 30 cc then discardthis urine

(iv) Have patient void directly into the sterilecontainer

(v) Have patient stop before he empties bladder(vi) Return foreskin to its normal position to prevent

swelling and irritation of the glans penis


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NOTE: With male patients, a sterile urinal may be used if unable to urinateinto cup. With female patients, a sterile bedpan may be used ifunable to urinate into cup.

(d) Label specimen container appropriately and sendspecimen to the laboratory

Blood cultures are used to identify a disease-causing organism especially in patients

who spike temperatures for unknown reasons

Procedure(1) Explain the reason for the procedure to the patient(2) Gather all supplies and equipment and bring to the patient's bedside(3) Make the patient as comfortable as possible in bed(4) If patient is uncooperative or disoriented you may need assistance(5) Clean the tops of all bottles with a betadine solution(6) Attach the needle to the syringe(7) Apply the tourniquet(8) Don gloves and clean the drawing site with a betadine solution(9) Wash hands(10) Draw at least 10 cc of blood from the patient (5 cc's is needed for

each bottle)(11) Loosen the tourniquet(12) Remove the syringe and needle while applying pressure to the site(13) Replace the needle on the syringe with another sterile needle

(14) Inject 5 cc of blood into anaerobic bottle and do not allow air to enterthe bottle

(15) Replace the needle on the syringe with another sterile needle(16) Inject 5 cc of blood in the aerobic bottle and while the needle is still in

the bottle, disconnect it from the syringe so that air enters theaerobic bottle, if IAW local SOP.

(17) Gently mix the blood with the solution in both bottles(18) Label both bottles with patient identifying information and type of

culture, ie, aerobic or anaerobic(19) Prepare lab slip and take slips and specimens to the lab immediately(20) Place a band aid over the patient's venipuncture site


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Obtain and Label Blood Specimens

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Obtain a blood specimen while maintaining aseptic technique and without causing injuryto the patient.

General Considerations

Terms and definitions

(1) Venipuncture - the transcutaneous puncture of a vein to withdraw aspecimen of blood, start an IV or instill a medication(2) Palpate - to feel or to examine by hand(3) Antecubital fossa - hollow or depressed area at the bend of the

elbow(4) Anticoagulant - substance that prevents or delays clotting of the

blood(5) Hematoma - swelling or mass of blood confined to an organ, tissue,

or space and caused by a break in a blood vesselVeins used for drawing blood(1) Median cubital vein - first choice, well supported, least apt to roll(2) Cephalic vein - second choice(3) Basilic vein - third choice, often the most prominent vein, but it tends

to roll easily and makes venipuncture difficult

Steps and Procedures to Perform a Venipuncture

CAUTION: Universal precautions for this task will include hand washing andgloves.

CAUTION: Strict adherence to the sharps policy and the use of sharpscontainers will be utilized during this hands on exercise.

Verify the request to obtain a blood specimen. Check the physician'sordersSelect the proper blood specimen tube for the test to be performed.Check local laboratory SOP(1) The type of blood tube needed will depend on the specific test to be

performed(2) For some tests, an anticoagulant or other additives are

present in the tube(3) Rubber stoppers of the tubes are color-coded for different testsPrepare label(s)(1) Stamp label with patient's addressograph plate. If there is no plate,

write name, organization, social security number, prefix code, wardor clinic, facility, and date.

(2) Apply to specimen tubePerform a patient care hand wash/don glovesGather equipment(1) Constricting band(2) Vacutainer sleeve/holder(3) Sterile disposable double-ended needle


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(a) Single specimen vacutainer needle(b) Multiple samples - a rubber sheath covers the shaft of the

needle. It is pushed up when the blood tube is insertedonto the needle then slips back over the needle holderwhile tubes are being changed to prevent blood fromdripping into holder

(4) Betadine or alcohol wipe or sponge

CAUTION: Always ask the patient if he/she has an allergy to iodine or Betadinebefore applying.

(5) Protective pad (chux)(6) Sterile 2 x 2-inch gauze sponge(s)(7) Band-AidAssemble vacutainer and needle(1) Put short end of needle into threaded hole in vacutainer(2) Screw tightly using clockwise motionInsert rubber stoppered end of the specimen tube into vacutainer holderand advance the tube until it is even with the guideline

CAUTION: If the tube is pushed beyond the guideline, the vacuum may releasedand blood will not be pulled into the tube.

Identify patient

Explain the procedure and purpose for collecting the blood specimen tothe patient

CAUTION: Ask patient about allergies (i.e., iodine or alcohol).

Position the patient - sitting or lying

CAUTION: Never attempt to draw blood from a standing patient.

Position protective pad under patient's extended elbow and forearm

Expose area for venipuncture(1) Roll garment above the elbow(2) Extend patient's arm with palm upSelect vein for venipuncture - Palpate and select one of the mostprominent veins in antecubital fossa

CAUTION: You may need to apply the constricting band at this point forvenipuncture site selection.

Prepare sponges for use(1) Open the betadine or alcohol and 2 x 2 gauze sponge packages(2) Place them within easy reach (still in the packages)Apply constricting band with enough pressure to stop venous returnwithout stopping the arterial flow. A radial pulse should be felt


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(1) Wrap latex tubing around limb about 2 inches above venipuncturesite

(2) Stretch tubing slightly and hold with one end longer than the other(3) Loop longer end and draw under shorter end so tails are away from

site(4) If a commercial band is used, wrap it around limb as in step 14a and

secure by overlapping Velcro ends.(5) Instruct patient to clench and unclench his fist several times and then

hold clenched fist to trap blood in veins and distend them.

CAUTION: Avoid veins that are infected, injured, irritated, or have an IV runningdistally.

Palpate selected vein(1) Palpate along length of vein with index finger up and down 1 or 2

inches from selected site in both directions so size and direction ofvein can be determined.

(2) Vein should feel like a spongy tubeClean the skin - moving alcohol/betadine wipe in a circular motion awayfrom selected venipuncture site.

CAUTION: Do not repalpate the vein after cleansing the skin.

Prepare to puncture vein(1) Remove protective cover from needle

(2) Position needle in line with vein and grasp patient's arm below entrypoint with free hand

(3) Place thumb of free hand 1 inch below entry site and pull skin tauttoward hand

Puncture vein(1) Align needle, bevel up, with the vein and pierce skin at 15 to 30

degree angle(2) Decrease angle until almost parallel to skin surface, then pierce vein

wall(a) A faint "give" will be felt when the vein is entered, and

blood will appear in the needle(b) If venipuncture is unsuccessful, pull needle back slightly

(not above the skin surface), and redirect needle towardvein and try again

CAUTION: If needle is withdrawn above skin surface, do not attemptvenipuncture again with the same needle.

(c) If still unsuccessful(i) Release the constricting band(ii) Place 2 x 2 gauze sponge over site(iii) Quickly withdraw the needle and instruct the

patient to elevate arm slightly and keeping thearm fully extended apply pressure to the site for2 to 3 minutes.


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(iv) Notify supervisor before attempting anothervenipuncture

Collect the specimen(1) Single specimen

(a) Hold vacutainer unit and needle steady with dominanthand. Collection tube is positioned against, but notthrough, the needle

(b) Place index and middle fingers of other hand behind flange

of vacutainer(c) Push the tube as far forward as possible with thumb ofnondominant hand without causing excessive movement

(d) Instruct patient to relax and unclench fist after blood hasstarted flowing

(e) Release the constricting band by pulling on long end oflooped tubing or releasing Velcro fastener with the nondominant hand

(f) When tube is about two-thirds full of blood or blood stops,grasp tube firmly and remove tubes

(g) Prepare to withdraw needle(2) Multiple specimens

(a) Follow same steps for collecting single specimen(b) Remove first tube from vacutainer sleeve without

dislodging needle position(c) Insert second tube into vacutainer sleeve. Push tube as

far forward as possible without causing excessive

movement.(d) Repeat these procedures until the desired number of tubes

are filled or blood stops flowing(e) Release the constricting band by pulling on long end of

looped tubing or releasing Velcro fastener with the nondominant hand.

CAUTION: DO NOT withdraw the needle before the constricting band isreleased because of potential for heavy blood loss and/or hematomaformation.

(f) After the last tube is about two-thirds full of blood or bloodstops, grasp tube firmly and remove tubes

(g) Place 2 x 2-inch sponge lightly over venipuncture site(h) Withdraw the needle smoothly and quickly. Immediately

apply pressure to the site with the 2 x 2-inch sponge,keeping patient's arm fully extended.

(i) Instruct the patient to elevate arm slightly and keeping thearm fully extended, apply firm manual pressure for 2 to 3minutes. If the patient is unable to do this for himself, youmust do it for him.

If specimen tube contains an anticoagulant or other additive, gentlyinvert tube several times to mix with bloodApply a band aid to the venipuncture site after the bleeding has stopped


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CAUTION: Dispose of needle into sharps container as soon as possible or IAWlocal protocol. DO NOT unscrew needle from sleeve with hands. DONOT recap needle.

Provide for patient's comfort and safety(1) Remove protective pad(2) Roll down patient's sleeve(3) Reposition patient and raise side rails if patient is in a bed

Dispose of equipment(1) Remove all the equipment from area(2) Dispose of used supplies(3) Store reusable equipment and dispo

Supportive Care 2

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Transcript of Supportive Care 2